Help, I ve Fallen and Can t Get Up! Evidence-Based Strategies for Fall Prevention in Community- Dwelling Older Adults

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1 Help, I ve Fallen and Can t Get Up! Evidence-Based Strategies for Fall Prevention in Community- Dwelling Older Adults Jean F. Wyman, PhD, GNP, FAAN Center for Gerontological Nursing School of Nursing University of Minnesota Minneapolis, MN 1

2 Falls Are Prevalent 33% aged 65+ years 50% aged 80+ years Rates are highest in women 40-50% of fallers will have repeat falls

3 Falls Are Morbid Events Falls are the 8th leading cause of death in older adults 1 Mortality risk increases with advancing age, especially in those aged 80+ White and black males have highest death rates Black women have lowest death rate 33% of hip fracture patients will die within 1 year of injury, with rates highest in men 2 1 Centers for Disease Control, Jiang HX et al. J Bone Miner Res 2005;20:

4 Fatal and Nonfatal Fall Injuries Among People 65+, U.S million 12, ,000 1,230,000 1% - Died 24% - Treated in ED & hospitalized 76% - Treated in ED and released? Millions Fall related injuries Nonfatal falls: NEISS-AIP, 2002 Fall deaths: NCHS, Vital Records, 2002

5 Severity of Fall Injuries Injury % of All Falls Minor soft tissue injuries: Serious injuries: Fractures: 2-10 Hip Fracture: 1-2 Other common sites: Vertebrae, forearm, leg, ankle, pelvis, upper arm, & hand Injury rates highest in women with fracture diagnoses 2.2 times more common

6 Falls Lead to Functional Decline 25-75% of hip fracture patients do not recover prefracture level of function in ambulation or activities of daily living 1 Fallers have greater functional decline at 1 and 3 yrs than nonfallers 2 1 Magaziner J et al. J Gerontol Med Sci 1990;45:M101-M107 2 Tinetti ME & Williams CS. J Gerontol A Biol Sci Med Sci, 1998;53;M112-M119

7 Falls Lead to Fear and Loss of Confidence In a large population-based study of adults aged 72 and over 1 24% report a fear of falling 19% restrict activity because of their fear In other studies, fear of falling: Increases with age Is higher in women Is present both nonfallers and fallers 1 Stevens JA, Sogolow ED. Inj Prev 2005; 22:

8 Falls are Expensive $7.8 billion in total direct medical costs of fall-related care for adults aged 65+ in adjusted 2002 dollars (using 1997 fall & cost data) 1 Acute medical care costs: 2 Hospitalization: $17,483 Emergency Department visit: $ 236 Outpatient office visit: $ Carroll NV, Slattum PW, Cox FM. J Manag Care Pharm 2005;11: Roudsari BS, Ebel BE, Corso PS et al. Injury 2005;36;

9 Falls Affect Others Impact on caregiver Emotional Lost productivity Financial cost

10 Fall Etiology: Interaction Between Multiple Factors Older Person Age associated changes Chronic diseases Acute illness, hospitalization Medications Challenges to Postural Control Environmental hazards Usual activities Changing position Mediating Factors Risk-taking behavior Opportunity Mobility Physical activity Fall King MB & Tinetti ME. J Am Geriatr Soc 1995; 43:

11 Falls are Predictable % Percent Falling % 19% 32% 60% Number of Fall Risk Factors Tinetti ME, Speechley M, & Ginter SF. N Engl J Med 1988; 319:

12 Risk Factors for Falls: (N = 16 Multivariate Studies) Relative Risk Ratio (RR) or Odds Ratio (OR) Predicting Falls Muscle weakness History of falls Gait deficit Balance deficit Use assistive device Visual deficit Arthritis Impaired ADL Depression Cognitive impairment Age > 80 years AGS, BGS, & AAOS Panel on Falls Prevention. J Am Geriatr Soc, 2001; 49: Mean RR or OR

13 Medication Use Increases Fall Risk 4 or more medications Recent dosage change Drug type: Neuroleptics (especially phenothiazines) Sedatives, hypnotics (including benzodiazepines) Antidepressants (eg, TCAs, MAOIs, SSRIs, SNRIs) Antiarrhymthmics (Class 1A) Quinidine, procainamide, disopyramide Anticonvulsants Glitazones Alcohol

14 The Environment Can Cause Falls Slippery or uneven surfaces Poor lighting (dim, glare) Cluttered pathways Tripping hazards (cords, throw rugs) Unstable furniture (eg, too low or high, on casters, pedestal tables) Shelves too high or low Clothing and footwear

15 Fall Prevention Principles Identify high risk individuals Treat underlying disease Reduce modifiable fall risk factors Promote maximal functional ability and mobility Optimize bone strength and protection

16 Cochrane Review (2003): What Interventions Work? In a review of 62 randomized controlled trials, strategies determined as likely to be effective were: Multidisciplinary, comprehensive risk factor screening and intervention programs Unselected populations in the community Those with history of falling Those with known risk factors Gillespie LD, Gillespie WJ, Robertson MC et al. Cochrane Database Syst Rev 2003;4:CD000340

17 Cochrane Review (2003): What Interventions Work? Exercise for balance and strength individually prescribed by a trained professional Tai Chi group exercise program Home hazard assessment & modification professionally prescribed for the older faller Discontinuation of psychotropic medication Gillespie LD, Gillespie WJ, Robertson MC et al. Cochrane Database Syst Rev 2003;4:CD000340

18 Rand Meta-Analysis of Fall Prevention Trials (2004) In a review of 40 randomized controlled trials: Combining all types of interventions, there was a significant reduction in risk of falling and monthly rate of falling Most effective: multifactorial assessment and management program Next most effective: exercise (reduces falls by 13%- 24%) No effect: home modifications and education Chang JT, Morton SC, Rubenstein LZ et al. 2004;BMJ;328:

19 Optimizing Bone Strength: Protecting Against Fractures Weight-bearing exercise and strength training If no contraindications, minimum supplementation of calcium (1,200 mg/d) and vitamin D ( mg/d) However, evidence from the Women s Health Initiative using calcium carbonate (1000 mg/d) plus vitamin D (400 IU/d) in 32,282 postmenopausal women aged years reported: Although hip bone density was higher in the calcium plus vitamin D group than placebo, it did NOT significantly reduce hip fractures and it increased kidney stone risk Jackson RD, et al. N Engl J Med 2006;354:

20 Optimizing Bone Strength: Protecting Against Fractures For the older adult at high risk of fracture: Drug therapy Bisphosphonate therapy (e.g., alendronate, risendronate) Selective estrogen receptor modulators (raloxifene) Hormone replacement therapy in selected patients Synthetic parathyroid hormone (teriparatide) Calcitonin in those with prior osteoporotic fractures Hip protectors

21 Cochrane Review: Hip Protectors (2004) Meta-analysis of 14 randomized controlled trials of hip protectors in long-term care institution or community No evidence on effectiveness from studies in which randomization was by individual patient within institution or by those living at home Some evidence of effectiveness from cluster randomized studies for older adults at high risk of hip fracture living in institutional settings Adherence/compliance is a problem which may be related to skin irritation, abrasion, and local discomfort Parker MJ, Gillespie LD, Gillespie WJ. Cochrane Database Syst Rev. 2004;3:CD001255

22 Fall Evaluation & Prevention Program Trial National Institute of Nursing Research and Office of Research on Women s Health, National Institutes of Health (R01 NR05107) 22

23 Purpose Test the efficacy of a multifactorial fall prevention program (exercise, education, tailored counseling) in reducing falls in community-dwelling older women deemed at risk for falling

24 Intervention Components Comprehensive fall risk assessment by nurse practitioner Home-based exercise program Fall prevention education Tailored risk reduction counseling Provision of 2 nightlights

25 Program Length 28 week program in 2 phases: 12 weeks, alternating weekly home visits and telephone calls by registered nurses 16 weeks, tapered interactive computerized telephone calls for support and monitoring

26 Exercise Program Incorporated principles from Transtheoretical Model of Behavior Change Developing awareness Helping relationship Goal setting Personal testimonies Identifying rewards for exercise adherence Exercise monitoring with daily logs Teaching exercise relapse prevention strategies Exercise regimen Walking program (30 minutes for minimum 5 days/week) Balance, strength, and coordination exercises

27 Exercises 12 repetitions, twice a week Alternate knee touches Sideway walking Crossover stepping Tandem walking Toe lifts Sit to stand* Heel lifts* Single leg stand* Hip abduction* Hip extension* Step ups* * Done while wearing weighted belt

28 Fall Prevention Education Fall causes Safety proofing home Safe medication use Taking time -Avoiding rushing -Getting up slowly -Answering phone calls -Walking on ice/ slippery surfaces Balance tips for daily activities Limiting alcohol use Vision care and lighting Foot care and shoe selection Osteoporosis prevention Urinary control strategies Getting up from a fall

29 Tailored Risk Reduction Counseling Based on comprehensive fall risk assessment Written fall risk profile developed and shared Counseling with mutual goal setting and action plan for 3 fall risk factors Referrals provided as needed to health care providers, medical equipment suppliers, and handimen services

30 Sample Characteristics Mean age: 79 years (range 70-99) 98% white 60% high school education 52% $20,000/year incomes 39% fell in past year Average of 3 chronic conditions for which they took 3.5 drugs/week 8% used a cane or walker

31 Fall Frequency at 2-Years Percent of Participants or more Number of Falls Fall Prevention Health Education

32 Fall Rate Per 100 Person Years at 1- and 2-Years Follow- Up Fall Prevention Heath Education Incidence Rate Ratio (95% Confidence Interval) 1-Year* ( ) 2-Year** ( ) *P <.01 ** P <.001

33 How Much Can the Fall Prevention Program Reduce Falls? 35% fall reduction at 1 and 2 years Time Period 1-year Risk Factors Highly Predictive of Falls Older age Number of falls in prior year Number of medications with fall risk Urge incontinence Cardiovascular disease Severe hearing loss Poor vision Stroke 2-years Number of falls in prior year Number of medications with fall risk Poor vision

34 Fall-Related Injuries Over 2-Years N um ber of Falls Fall Prevention (148 falls) Health Education (238 falls) None Minor Moderate or Severe Number of Falls Fall Prevention Health Education Severity of Injury Number of Falls Resulting in Fractures

35 Fall Rates per 100 Person- Years by Exercise Adherence at 2 Years Walking Low High Balance Low High 63.7 (n=50) 82.1 (n=16) 58.0 (n=15) 40.9 (n=50

36 Conclusions Falls are common, serious, and costly in older adults Falls are multifactorial in origin, with several interacting causes Falls are preventable with multicomponent programs most effective

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